Profile of calories and nutrients intake in a Brazilian multicenter study of nulliparous women

Abstract Objective To assess the calorie intake and nutritional content of the maternal diet in regions with different culinary traditions and typical foods, and to understand the nutritional profile so as to provide information about the consumption of this population and promote maternal and perinatal health. Methods From a cohort of 1145 pregnant women with diverse socio‐backgrounds we analyzed the dietary characteristics profile according to three guidelines and compared the differences between regions of Brazil. Results Women from the northeast had the lowest level of income, occupation, education, and age (P < 0.001). Intakes of unprocessed/minimally processed foods and processed foods were more prevalent in women from the northeast than in southern/southeastern women (P < 0.001). The consumption of dairy products and vegetables was less than the recommended intake, with lower intake in southern/southeastern women (P < 0.001). This study showed a lower consumption of dairy and vegetables, with a shortfall of vitamins K and D, iron, calcium, folate, magnesium, and chromium from natural and fortified foods. We observed a greater consumption of unprocessed or minimally processed food in women from the northeast of Brazil. Conclusion Our findings indicate the importance of differentiating the source of calorie intake between regional nutritional guidance and the diversity of local cuisine.


| INTRODUC TI ON
Optimal maternal nutritional status is the result of adequate diet, body composition, and nutritional requirements during pregnancy. 1 In the past, malnutrition was linked to famine resulting from food deprivation causing chronic energy deficiency and weight loss. A study of obstetric birth records from the time of the Dutch famine (1944)(1945) found that women exposed to food deprivation during the antenatal period gave birth to smaller newborns compared with the periods before and after the Second World War. 2 In the last decades, however, there has been a global epidemiological phenomenon referred to as "hidden hunger", in which a diet has excess total calories, but is poor in micronutrients. 3 A maternal diet with high quantities of calories and lower nutrients increases the risk for maternal obesity, gestational diabetes, hypertensive disorders, and large-or small-for-gestational-age newborns. 4 Nutrition transition is a global burden where people exchange a meal prepared with natural or minimally processed foods for fast food or "readyto-eat, ready-to-heat" meals that belong to the ultra-processed food groups, which are rich in calories and poor in nutrients. 5 Nowadays, malnutrition coexists with obesity, causing non-communicable diseases related to diet, and increasing the need for evaluating and recommending healthier and more sustainable diets. 6 The present study aimed to discover the dietary habits of pregnant women in different regions of the country using a broad approach to caloric density, which is a new method to evaluate food consumption involving three guidelines for the caloric assessment of foods and the ability to supply vitamins and minerals. Data were obtained from different contexts and food patterns in Brazil. In the Brazilian northeast, there is a hot and humid climate and there a variety of fresh fruits, cassava, couscous, coconut, beans, and nuts from Pará are widely used in the traditional gastronomy. In the south and southeast regions, the climate is milder and people generally consume rice and beans, potatoes, pasta, and more red meat and chicken. 7 With the variety of nutritional patterns in a country as diverse as Brazil, our aim was to assess the calorie intake and the nutritional content of the maternal diet according to region. With each region's culinary traditions and typical foods, we aimed to understand the nutritional profiles so as to provide information about the consumption of these populations and to contribute to promoting maternal and perinatal health.

| MATERIAL S AND ME THODS
This study is an analysis of secondary objectives from the multicenter prospective cohort study "Preterm SAMBA-Preterm Screening And Metabolomics in Brazil and Auckland", 8 involving a comprehensive cohort with nulliparous women from any economic and educational status without serious comorbidities at 19-21 weeks of pregnancy when entering the study. The study was held between July 2015 and July 2018 in five public tertiary hospitals for specialized obstetric care in different geographical regions of Brazil: Recife and Fortaleza in the northeast, with a mean lower income; Porto Alegre in the south; and Campinas and Botucatu in the southeast, with the highest mean incomes in the country.
The included criteria were women who were pregnant for the first time or nulliparous women, with a singleton pregnancy, who responded to the 24-h diet recall interview and who were between 19 and 21 weeks pregnant (Fig. 1). Gestational age was confirmed by an early ultrasonography. Exclusion criteria were any risks associated with preterm birth, provision of special diet counseling, maternal chronic illness, and a reproductive history with more than two previous abortions. Women were also not included in the study in cases of cervical suture; fetal malformation; chronic hypertension requiring antihypertensive drugs; diabetes or renal disease as self-reported by the women themselves; arterial blood pressure equal to or above 160/100 mm Hg on enrollment; systemic lupus erythematosus or antiphospholipid syndrome; sickle cell disease; HIV infection; Müllerian anomalies; history of cervical knife cone biopsy; chronic use of corticosteroids, aspirin, calcium, fish oil, vitamin C, vitamin E or heparin. All centers used nutritional assessment tools (anthropometry and 24-h recall dietary intake), on the first visit. Diagnostic criteria for hypertension in pregnancy and diabetes mellitus followed international guidelines. 9,10 Data on newborn weight, length and head circumference were evaluated according to the World Health Organization guidelines and placenta weight was also collected. 11 Sociodemographic characteristics were self-reported. All data were inserted in an electronic platform (MedSciNet AB).
This study aimed to assess the mean dietary values of the meal preparation and serving size details from two population groups, using a single day of intake recorded per person through one 24-h diet recall, which, according to Willett,12 is adequate for the profile of this study. Interviews were performed by trained local staff using the multi-step method. 13 We estimated serving sizes based on a photographic album of household measures. To standardize servings, household measures were converted into grams or milliliters of consumption using Brazilian reference manuals. 14 The type and amount of meal intakes were listed for breakfast, lunch, snacks (morning and afternoon) and dinner.
The nutrients selected for assessment were evaluated using the estimated average requirements (EAR) or adequate intake, and were adopted according to dietary reference intakes (DRIs) for pregnant women. 15 To analyze these specific nutrients, food composition, data from Brazilian tables, and the National Nutrient Database for Standard Reference of the US Department of Agriculture were used. 16,17 We also extracted information from industrial food labels and cooking recipes. dietWiN ® PluS software (version 3090) was used for all data collection and dietary analyses.
Energy was calculated from the amount of foods and was divided into groups defined by their characteristics of food sources and degrees of processing. The total diet and the calories consumed were therefore organized and analyzed according to the criteria of three guidelines, respectively: the DRIs, the NOVA classification, and the Brazilian Food Pyramid. 15,18, 19 We assessed total energy intake from the DRIs and compared their adequacy with standard recommendations. Calorie quality by the degree of processing of food was assessed according to the NOVA Food classification. The characteristic of calories in each predominant food group was detailed using the Food Pyramid. To calculate the estimated energy requirement of basal metabolism in calories, the predictive equation indicated in the DRIs was used. Data collection of the NOVA food regimens followed procedures according to the three food groups in the classification: ultra-processed (UPF), processed (PF) and unprocessed or minimally processed (UMPF) foods. We added fats, salt, and sugars into culinary preparation, computed as UMPF. Calories and grams for each selected group were then calculated.
From the total sample, pregnant women enrolled were allocated into two groups: northeast (NE) and south/southeast (S/SE) of Brazil, according to the region in which they lived. Descriptive statistics were calculated and presented as number (percentage), mean (standard deviation), or median. To compare socioeconomic and maternal outcome differences between regions, the χ 2 test was applied for categorical variables. For the nutrients of maternal diet, data variables were analyzed using Mann-Whitney tests to compare the maternal differences between regions, and the normality tests Kolmogorov-Smirnov, Shapiro-Wilk and Anderson-Darling.
All results with a P value below 0.05 were considered significant.
The software/program R 3.6.1 was used (R Foundation for Statistical

| RE SULTS
From the total of women included in the Preterm-SAMBA study, a total of 1145 women met criteria for this analysis according to the flowchart in Figure 1.   Calorie quality is shown in Figure 3, according to the three degrees of food processing (NOVA Food

| DISCUSS ION
This study confirmed that the adequacy of energy intake cannot reflect the quality of the nutritional content, with a deficit of >60% In summary, our results showed that the eating habits of the regions of Brazil had widely been influenced by the same pattern for the deficiencies or excess of vitamins and minerals of food sources. We observed poor consumption of dairy and vegetables, insufficient intake of vitamins K and D, and of minerals iron, calcium, folate, magnesium, and chromium from both natural and fortified foods. However, women in the NE region appear to be less affected by the food processing industry compared with women in the S/SE. We suggest that dietary patterns should not be evaluated in isolation, but according to the sources of calories, and the characteristics of regional cuisines, to avoid the lack of nutrients. This study outlined a profile of maternal nutrition from different cultures in Brazil; however, new studies could evaluate the best interventionist approach to improve nutritional status in pregnancy. Federal University of Ceará, Fortaleza, Brazil. We are also grateful to our colleague Jacqueline Tereza da Silva for her preliminary support in the data mining.

CO N FLI C T S O F I NTE R E S T
The authors have no conflicts of interest. The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported. The reporting of this work is compliant with STROBE guidelines. The lead author affirms that no important aspects of the study have been omitted.